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Triple Jeopardy: Low Income, Chronically Ill and Uninsured in America

Issue Brief No. 49February 2002
Marie C. Reed, Ha T. Tu

t least 7.4 million working-age Americans with chronic conditions-such as
diabetes, heart disease and depression-lacked health insurance in 1999, according
to new research findings from the Center for Studying Health System Change
(HSC). Uninsured people with chronic conditions report worse health and more
functional limitations and are three times more likely not to get needed medical
care compared to those who are privately insured. The vast majority of uninsured
people with chronic conditions delayed or did not get needed care because of cost.
About 63 percent of the uninsured with chronic conditions-roughly 4.7 million
Americans-have family incomes below 200 percent of poverty, or about $35,000 a
year for a family of four in 2001. Faced with the triple threat of low income, ongoing
health problems and no health insurance, this group confronts great difficulty
getting and paying for needed care.

Chronic Conditions Widespread Among Working-Age Adults

ecause chronic health problems typically increase as people
age, chronic illness often is perceived primarily as a problem of the elderly.
Yet, chronic illness affects more than a third of working-age Americans (18 to
64). In 1999, 37 percent of nonelderly adults, or about 60 million working-age
Americans, reported seeing a doctor in the past two years for at least one chronic
condition, according to HSCs Community Tracking Study (CTS) Household Survey
(see Methodology).

Nonelderly adults with chronic conditions are more likely to have health insurance
than people without chronic conditions-88 percent vs. 81 percent in 1999.1
At that time, 71 percent of working-age adults with chronic conditions were privately
insured; 12 percent were uninsured; 14 percent were covered by Medicare and/or
Medicaid; and the remainder had other coverage such as military insurance.

Chronic conditions can range from
mild to severe. In some cases, people
with chronic conditions experience
few limitations, while others cannot
perform the normal tasks of daily living
without help. Good access to preventive
and ongoing medical care for
people with chronic conditions can
alleviate pain and suffering, improve
productivity and minimize future
health problems and related costs.
For example, people with diabetes
who do not receive routine preventive
care, including eye exams, foot exams,
glucose screenings, cholesterol screenings
and blood pressure measurements,
are at higher risk for blindness, kidney
failure and amputations. And, health
insurance coverage plays an important
and well-documented role in improving
access to medical care.

Methodology

The findings for this Issue Brief
are based on an analysis of the
1998-99 CTS Household Survey.
The survey asked respondents
aged 18 to 64 whether they had
been diagnosed with one of more
than 20 chronic conditions and
had seen a doctor in the past two
years for the condition. The list
of chronic conditions includes
asthma, diabetes, arthritis,
chronic obstructive pulmonary
disease, heart disease, stroke,
hypertension, high cholesterol,
cancer (skin, lung, prostate, breast,
colon), benign prostate enlargement,
abnormal uterine bleeding,
severe headaches, cataracts,
HIV/AIDS and depression.

Because the CTS list of conditions is not exhaustive, the estimate of the prevalence
of chronic conditions is likely somewhat conservative. In comparison, 41 percent
of working-age adults reported at least one chronic condition in the 1996 Medical
Expenditure Panel Survey.2

Uninsured with Chronic Conditions in Worse Health

onventional wisdom holds that the uninsured tend to have better
health than the insured, and CTS findings show that fewer of the uninsured reported
a chronic condition than did working-age adults with private insurance-27 percent
vs. 35 percent.3 Regardless of insurance status, people
with chronic conditions reported an average of 1.6 conditions. But, the uninsured
with chronic conditions reported much worse health and significantly more severe
physical limitations than privately insured people with chronic conditions (see
Figure 1).

Nearly 40 percent of the uninsured with
chronic conditions indicated they were in
fair or poor health, compared to less than 20
percent of the privately insured with chronic
conditions. In addition, the uninsured were
twice as likely to report having physical limitations
that significantly restricted their ability
to perform moderate activities such as
moving a table or pushing a vacuum cleaner.

Uninsured Far Less Likely to Get Needed Care

ninsured people with chronic conditions are particularly at
risk for not obtaining medical care when needed (see Table 1).
More than a quarter said they hadnt obtained needed medical care at least once
in the past year, compared to less than 10 percent of the privately insured with
chronic conditions. And, more than half of the uninsured with chronic conditions
delayed care in the past year, while only about a quarter of those with private
insurance postponed care. This was true even after adjusting for health status.4

The negative effects of being uninsured
are substantially greater for working-age
adults with chronic conditions than for
those without any such conditions. The
uninsured with chronic conditions were
3.3 times more likely not to obtain needed
medical care than the privately insured,
while the uninsured without chronic conditions
were 2.7 times more likely not to
obtain needed care-a 20 percent differential.
The differential for delaying care
was even greater-more than 35 percent.

Table 1
Level of Risk for Delaying or Not Obtaining Care (Percent of persons by
chronic condition and insurance status)

Major Barrier to Care: Cost

he uninsured with chronic conditions tend
to have much lower incomes, and cost is
the major barrier to care for the uninsured,
much more so than for the privately insured
with chronic conditions. Sixty-three percent
of the uninsured with chronic conditions
had family incomes of less than 200 percent
of poverty, compared to 18 percent of the
privately insured with chronic conditions.

The vast majority of the uninsured with chronic conditions who delayed or did
not get needed care in the previous year did so because of cost concerns (see
Figure 2). In contrast, less than half of the privately insured with chronic
conditions who delayed care did so because of cost issues.

Figure 2Working-Age Adults with Chronic Conditions Who Delayed or Did Not Obtain Needed Care

Health Care Services Received

n spite of difficulties getting needed care in a timely manner,
most people with chronic illnesses do receive some care (see
Table 2). While it is unclear that all treatment received by the privately
insured with chronic conditions is appropriate and needed-or that all of the care
needed is provided or coordinated properly- it is clear that the uninsured with
chronic conditions receive significantly less medical care, even after adjustments
for health status.

For example, almost 25 percent of
uninsured people with chronic conditions
did not see a doctor at least once in the
past year, compared to less than 10 percent
of the privately insured. The uninsured
reported an average of four doctor visits,
about 30 percent fewer than those with
private insurance. While the two groups
had about equal numbers of hospital
admissions on average, the uninsured
underwent about half the number of surgeries,
even after adjusting for health status,
suggesting the uninsured with chronic illnesses
may receive less intensive medical
intervention.

Lack of health insurance likely contributes to inappropriate use of emergency
departments by people with chronic conditions, resulting in higher costs and possible
capacity problems for the health care system. Compared to the privately insured,
the uninsured with chronic conditions reported almost twice the number of emergency
room visits.

Table 2
Health Service Utilization by People with Chronic Conditions

Uninsured

Privately
Insured

Percent with at Least One Doctor Visit

74

92

Number of Doctor Visits (Mean)

4

5.6

Number of ER Visits (Mean)

0.81

0.43

Number of ER Visits Without Hospital Admission (Mean)

0.67

0.35

Number of Hospital Admissions, Excluding Childbirth (Mean)*

0.18

0.17

Number of Surgeries (Inpatient and Outpatient) (Mean)

0.15

0.28

* Uninsured and privately insured not significantly
different from each other.

Policy Implications

eople with chronic conditions are more
likely to be insured, presumably because they
value and need health insurance more than
people without ongoing health problems.
Many people with chronic conditions, however,
cannot obtain affordable coverage.

Overall, the uninsured with chronic conditions face more serious health problems
and more barriers to needed care than insured people with chronic conditions.
The long-term health implications of failing to receive preventive and ongoing
medical care can be serious for people with chronic conditions. Indirect costs
of chronic illness-lost workdays and sick pay-are considerable,5
and neglected care now may mean additional future productivity losses and costs
to the economy.

The added costs to the health care system
are both immediate and long-term.
Providing nonurgent care in emergency
departments is more expensive than providing
care in more appropriate sites. The
relatively high use of emergency departments
by the uninsured with chronic conditions
can contribute to hospital capacity
constraints that sometimes prompt emergency departments to divert ambulances to
other hospitals. Moreover, difficulties obtaining
care now may result in higher long-term
demand for more expensive services if the
lack of treatment results in more serious
health problems for those with chronic conditions.

Policy makers are debating different
proposals to expand health insurance coverage,
but none focuses specifically on the
segment of the uninsured population with
chronic conditions. Yet, because of their
medical needs, people with chronic illnesses
are precisely the ones who can benefit most
from insurance coverage-especially if they
also have low incomes.

Given the significant human and economic
costs of chronic illness, policy makers
should consider and assess the impact of
various coverage proposals on low-income,
uninsured people with chronic conditions.
The bottom line: health insurance counts
for this vulnerable group.